NBCE Part III key terms

The patient's own words describing the main symptom or concern that prompted the visit, recorded briefly and used to focus the interview and examination.

A chronological account of the current problem covering onset, duration, location, quality, severity, aggravating and relieving factors, and associated symptoms.

A structured set of questions screening each organ system for symptoms the patient may not volunteer, helping uncover conditions outside the presenting complaint.

A record of prior illnesses, surgeries, hospitalizations, medications, and allergies that may alter the diagnosis, treatment choice, or risk of an adverse outcome.

Measurement of joint movement produced by the patient (active) versus by the examiner (passive); the difference helps separate contractile from noncontractile tissue problems.

The band of skin supplied by a single spinal nerve root; sensory testing across these zones helps localize a nerve root lesion.

The group of muscles innervated by a single spinal nerve root; resisted testing of these groups helps identify the level of root involvement.

An involuntary muscle contraction elicited by tapping a tendon with a reflex hammer; grading the response from absent to hyperactive helps assess the reflex arc and nerve root.

Graded assessment of voluntary strength from zero (no contraction) to five (normal against resistance), performed to detect weakness from nerve, muscle, or tendon dysfunction.

A maneuver in which the supine patient's extended leg is raised; reproduction of leg pain below the knee at a limited angle suggests nerve root irritation or disc involvement.

Hands-on assessment of segmental joint movement during active or passive motion to identify restricted or altered motion, a common basis for selecting an adjustment.

The proportion of people who have a condition and test positive for it; a highly sensitive test is useful for ruling a condition out when the result is negative.

The proportion of people without a condition who test negative for it; a highly specific test is useful for ruling a condition in when the result is positive.

Two-dimensional images produced by x-rays, commonly used to assess alignment, bone integrity, and joint space; findings must be interpreted alongside the history and examination.

A method using a strong magnetic field and radio waves to depict soft tissue, discs, and the spinal cord; it is avoided in patients with certain implants or metallic foreign bodies.

Nerve conduction studies and needle electromyography that measure electrical activity in nerves and muscle, used to confirm and localize radiculopathy or peripheral nerve lesions.

A historical or examination finding suggesting serious pathology such as fracture, infection, tumor, or cord compression, prompting imaging or urgent referral rather than routine care.

A ranked list of conditions that could explain the patient's presentation, narrowed as findings accumulate until one diagnosis best accounts for the evidence.

The leading explanation for the patient's condition at a given time, stated clearly in the record and revised as new information becomes available.

Nerve root dysfunction producing pain, numbness, weakness, or reflex change in a specific dermatomal or myotomal pattern, often from disc herniation or foraminal narrowing.

Altered function of a spinal or somatic segment involving motion restriction, tenderness, and tissue texture change, a framework used in chiropractic diagnosis and technique selection.

A specific, controlled thrust applied to a vertebral segment to restore motion and reduce pain, usually delivered with high velocity and low amplitude.

Passive, graded movement of a joint applied at varying speeds and amplitudes without a thrust, used to improve mobility and reduce pain.

A condition in which a treatment should be withheld or modified because the risk of harm outweighs the expected benefit, such as fracture, malignancy, or segmental instability.

An unfavorable outcome occurring after treatment that may or may not be caused by it; recognizing, documenting, and discussing such events is part of safe practice.

Prescribed movement and strengthening designed to restore function, support the benefits of adjustment, and reduce recurrence, progressed according to the patient's tolerance and goals.

Directing a patient to another practitioner for care beyond the chiropractor's scope or expertise, communicated in writing with the relevant history and findings.

Shared care of a patient by two or more providers who coordinate findings, treatment, and goals while avoiding duplicated or conflicting interventions.

A written outline of the diagnosis, goals, visit frequency, expected duration, and methods of reassessment, revised whenever the patient's response warrants a change.

The point at which further treatment is unlikely to produce meaningful improvement; care is then reduced, discontinued, or the patient is referred for another opinion.

The patient's voluntary agreement to a procedure after receiving an explanation of its nature, benefits, risks, and alternatives, documented in the record.

The level and type of care a reasonably prudent practitioner with similar training would provide in similar circumstances; it is the benchmark in negligence claims.

The range of activities a licensed practitioner is legally permitted to perform, defined by statute, regulation, and professional standards in the jurisdiction of practice.

Failure to meet the standard of care that causes harm; it requires a duty, a breach of that duty, causation, and damages, all established by the plaintiff.

The duty to protect patient health information from unauthorized disclosure, with exceptions such as the patient's consent, legal requirements, or a serious threat of harm.

A progress note organized into subjective, objective, assessment, and plan sections that documents the encounter and supports the reasoning behind the diagnosis and treatment.

A running inventory of the patient's active and resolved problems, each linked to assessment and plan entries, allowing any reader to grasp the case quickly.

A correction or addition made to a record after the fact, dated and signed, that preserves the original entry rather than altering it and maintains the record's integrity.

The required period for keeping patient records, set by state law or professional guidelines, so documentation remains available for continuity of care, audits, and legal proceedings.